Decision making in global health: is everyone on board?
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2022)

Oxfam, in its response to The Lancet Commission on the COVID-19 pandemic published on Sept 14, stated that decisions about who lives and who dies must never be “outsourced to the CEOs of big pharma”. This sentiment, likely shared by most members of the global health community, raises the question: which global health groups do make the decisions that ultimately decide who lives and dies? And what is their suitability to make these decisions? A myriad of groups influence and fund global health, but an investigation published last month by POLITCO and Die Welt highlights how non-government organisations (NGOs) might have a bigger role than nation states or intergovernmental organisations. The report found that four NGOs (the Bill and Melinda Gates Foundation, Gavi, the Wellcome Trust, and the Coalition for Epidemic Preparedness Innovations [CEPI]) have spent almost US$10 billion to combat the COVID-19 pandemic since 2020. For comparison, the WHO total approved budget for 2020–21 was $9·4 billion. The Gates Foundation, Gavi, and the Wellcome Trust have donated $1·4 billion to WHO alone since 2020, often for specific aims—eg, global preparedness for yellow fever. The influence these donations would have has been augmented by these organisations spending $8·3 million lobbying American and European lawmakers. Who decides on the priorities of such organisations? Some insight into the decision-making process can be gleaned from the Global Health 5050 2022 report Boards for all? The report examines the demographics of 2014 board members of 146 organisations (including 62 NGOs and 35 for-profit companies) involved in global health. Boards nominate organisational leadership, set overall strategy, and provide oversight for financial decisions. The report found that, relative to the global burden of disease, nationals of low-income and middle-income countries (LMICs) and women were under-represented on global health boards. In the non-profit sector, only 30% of board seats were held by LMIC nationals and only 45% by women (and women who are LMIC nationals only made up 12%). The boards of 11 funder organisations (including the Gates Foundation and the Wellcome Trust) are even less representative: funders’ boards contained only 18% of seats occupied by LMIC nationals, 37% by women, and 7% by female LMIC nationals. Why is it important that boards are representative? The ultimate task, perhaps, for global health is to address the imbalance between wealthy nations and those with fewer resources. A situation that has arisen due to the exploitation of resources from non-wealthy nations by now high-income countries (HICs), and which has clear health outcomes, from medical purchasing power to the brain drain of expertise. Individuals from HICs continue to benefit from the imbalance (with some people in the decision-making positions of some NGOs benefitting the most) and, as such, can be oblivious to this imbalance and be unable to address it. More diverse boards also allow for local expertise to influence decision making, and for a broader range of experiences from which to draw ideas and solutions. Such expertise cannot be obtained by parachuting in external experts. Global health is, by its very nature, a multisector and multidisciplinary endeavour, and boards should represent this. All organisations involved in global health (including for-profit organisations) should have boards that are representative of the groups they serve, they should be publicly listed so they can be scrutinised, and these organisations should publish strategies on how they are addressing and aiming to resolve questions of board diversity, with time-bound targets. A representative board is unlikely to instantly realign an organisation's aims to perfectly concur with those of the disadvantaged but, providing these are not token appointments, would still be a valuable step. Before and during the COVID-19 pandemic, NGOs such as the Gates Foundation filled a void created by the deficit of preparedness and initiative shown by many national governments. As nations, such as the UK, continue to cut international aid budgets and turn their increasingly myopic gaze inward, the importance of such NGOs will only grow in all facets of global health, not just the COVID-19 pandemic. This increased importance will have to come with increased scrutiny, as NGOs impact greater and greater numbers of people. And if an organisation truly aims to aid a traditionally underserved community, members of that community should be involved in the decision-making process at the very top.